Attitudes toward Death among Health Care Professionals in the Balkan Region.

Background and Objectives: Death is an unavoidable experience in any person's life and affects not only the dying person but also their caregivers. The dying process has been displaced from homes to health care facilities in the majority of cases. Facing death and dying has become an everyday life of health care professionals (HCP), especially in palliative care (PC) settings. This study aimed to investigate the death attitudes among HCPs in Serbia. Materials and Methods: The Serbian version of the Death Attitude Profile-Revised (DAP-RSp) was used as a measurement instrument. Results: The average age of the 180 included participants was 42.2 ± 9.9 years; the majority were females (70.0%), with more than 10 years of working experience (73.0%), physicians (70.0%) and those working in a non-oncological (non-ONC) field (57.78%). The mean total score of DAP-RSp was 124.80 ± 22.44. The highest mean score was observed in the neutral acceptance dimension (NA) (5.82 ± 0.90) and lowest in the Escape acceptance (EA) (2.57 ± 1.21). Higher negative death attitudes were reported among nurses compared to physicians (p = 0.002). Statistically significant differences were observed in the fear of death (FD) and death avoidance (DA) domains, favoring PC specialists and oncologists (p = 0.004; p = 0.015). Physicians working in Oncology (ONC) showed lower FD values (p = 0.001) compared to non-ONC departments. Conclusions: Attitudes toward death among HCPs are of great importance for the well-being of both HCPs and patients. Negative attitudes can lead to deficient care. The fear of death is highly represented among Serbian HCPs working in non-ONC fields, including both nurses and physicians. This study emphasizes the need for further research to comprehensively explore and understand HCPs' attitudes toward death. This research highlights the need for the development of an educational curriculum across all levels of medical education, aimed at overcoming the fear of death and enhancing coping strategies, which will improve the care for patients diagnosed with terminal illnesses.

Modelling and optimisation of treatment parameters in high-dose-rate mono brachytherapy for localised prostate carcinoma using a multilayer artificial neural network and a genetic algorithm: Pilot study.

BACKGROUND: High-dose-rate mono brachytherapy (HDR-MB) is employed in the treatment of prostate carcinoma (CaP). As an ideal plan of CaP brachytherapy cannot be created, it is necessary to identify a reliable tool to optimise the parameters of HDR-MB. This paper applies a multilayer artificial neural network (MANN) and a genetic algorithm (GA) to optimise brachytherapy parameters based on an individual dose-volumetric analysis. METHODS: Patients with localised CaP of various risks were treated with HDR-MB. Consecutive levels of the biochemical control parameter (prostate specific antigen (PSA) nadir) have been collected after completion of HDR-MB in the range 2-9 years. The Kaplan-Meier regression analysis of biochemical-free survival (BFS) was applied. The clinical risk of recurrent CaP (RCaP), the therapy dose (TD), TD coverage index (CI100%) and PSA nadir were modelled using the MANN and GA. RESULTS: In the low-risk group, BFS was achieved in 100% of treated patients, while in the group of patients with high risk, BFS was achieved in 95.8% of treated patients. The MANN-GA model optimises a TD of 47.3 Gy and CI100% of 1.14 as well as a TD of 50.4 Gy and CI100% of 1.6 for the low-risk group and high-risk group, respectively, of localised CaP. The optimised PSA nadir was 0.047 and 0.25 ng cm-3 for low-risk group and high-risk group, respectively. CONCLUSIONS: The developed MANN-GA model presents a method for optimising the treatment parameters in radiation therapy, which could be a valuable tool in planning of the HDR-MB.

Cyanobacteria - insidious foe of the skin?

Cyanobacteria are ancient photosynthetic microorganisms that shaped today's atmosphere. Anthropocentric and irresponsible activities are changing the atmosphere which favor the frequent occurrence and mass development of cyanobacteria. Extensive cyanobacterial blooming causes numerous problems, including negative effects on human skin. Climate change, depletion of ozone layer, and the increased ultraviolet radiation also affect the skin and lead to more frequent occurrence of skin cancer. This research, for the first time, attempts to establish a connection between these two factors, or whether, in addition to ultraviolet radiation, cyanobacteria can influence the incidence of melanoma. With this objective in mind, an epidemiological investigation was conducted in Vojvodina, Serbia. It was observed that the incidence of melanoma was higher in municipalities where water bodies used for recreation, irrigation and fishing are blooming; however, results could be considered as inconclusive, because of the restrictions in the cancer database. Nevertheless, results gathered from the reviewed literature support the hypothesis that cyanobacteria could be a new potential risk factor for melanoma, while climate change could be a catalyst that converts these potential risk factors into cofactors, which act synergistically with the main risk factor - ultraviolet radiation - and induce an increase of melanoma incidence.

Modulatory effect of neoadjuvant chemotherapy on the prognosis of patients with breast cancer.

PURPOSE: To evaluate the changes in biological markers ER, PR, HER2 and Ki67 in residual tumor after surgery for locally advanced breast cancer (LABC), and also to evaluate the outcome of breast cancer patients treated with neoadjuvant chemotherapy (NAC). METHODS: 144 breast cancer patients treated with NAC at the Oncology Institute of Vojvodina, Serbia from 2011 to 2015 were included in this study. Changes in biologic markers ER,PR, HER2/neu and Ki-67 were evaluated at diagnostic core biopsy and at the final surgery tissue specimens. RESULTS: Of 144 patients pathological complete response was achieved in 17 (12%) and these were excluded from the study. Evaluated were 127 patients with residual tumor after the final surgery. A change in hormone receptor status (ER,PR) occurred in 9.4% of the patients (ER in 5%, PR in 14.5%) and HER2 status in 4.7% of the patients. ER and PR status change from negative to positive was associated with better overall survival (OS), but without statistical significance (p=0.16). Patients with conversion of HER2 status from negative to positive lived longer (65 vs 42 months). Furthermore, it was determined that HER2 change from negative to positive was associated with better OS (p=0.03). Ki-67 changed in 17 (11.8%) patients. The decrease of Ki-67 expression after NAC was associated with better outcome. Median follow up was 37.5 months (range 16.2-76.8). CONCLUSION: Changes in hormone receptor status, HER2 status and Ki-67 occurred after NAC in patients with LABC. A change from negative to positive hormone receptor status and HER2 status offers new treatment options, like endocrine therapy, and/or trastuzumab therapy for breast cancer patients. The decrease of Ki-67 expression after NAC was associated with better outcome.

MIA, S100 and LDH as important predictors of overall survival of patients with stage IIb and IIc melanoma.

PURPOSE: Melanoma represents the most severe form of skin cancer. Detection of specific tumor markers is an important step in disease diagnosis and treatment, contributing to personalized therapy. The purpose of this study was to evaluate the potential of MIA, S-100 and LDH as biomarkers for the estimation of overall survival and disease-free survival rate in patients with stage IIa, IIb vs stage IIc melanoma. METHODS: Selected biomarkers MIA, S-100 and LDH were prospectively evaluated in 80 patients with melanoma. Patients were divided in two groups according to tumor thickness. The first group (group A) consisted of patients with primary tumor thickness between 2.0 - 4.0 mm (N=40), i.e. IIa and IIb stage of disease (16 males; 40%, and 24 females; 60%). The second group (group B) consisted of 40 patients with primary tumor thickness over 4.0 mm, i.e. IIc stage, which is considered as high risk group (26 males; 65%, and 14 females 35%). Statistical analyses were performed to estimate overall survival and disease-free survival in both patient groups. RESULTS: In group A a significant difference in overall survival was found among MIA1, MIA2 and MIA3 scores, while the other 2 markers didn't show significant differences. In group B statistically significant differences in overall survival were found regarding all three biomarkers. Statistically significant differences in disease-free survival were found for MIA1 score compared to MIA2 and MIA3 scores. Also, very significant difference was detected in patients with S-100 below 0.106 and above 0.106. The same was confirmed for normal and increased LDH level in group B for disease-free survival. CONCLUSION: MIA score, S100 protein and LDH in the IIC group B patients might be useful in the prediction of overall survival and disease free survival.

Clinicopathological characteristics, diagnosis and treatment of melanoma in Serbia--the Melanoma Focus Study.

BACKGROUND/AIM: Treatment options for metastatic melanoma in Serbia are limited due to the lack of newly approved biologic agents and the lack of clinical studies. Also, there is a paucity of data regarding the treatment approaches in different tertiary centers and efficacy of available chemotherapy protocols. The aim of this study was to obtain more detailed data about treatment protocols in Serbia based on structured survey in tertiary oncology centers. METHODS: Data about the melanoma patients treated in 2011 were analyzed from hospital databases in 6 referent oncology centers in Serbia, based on the structured survey, with the focus on metastatic melanoma patients (unresectable stage IIIC and IV). RESULTS: A total of 986 (79-315 in different centers) patients were treated, with 320 (32.45%) newly diagnosed patients. There were 317 patients in stage IIIC/IV, 77/317 aged < 50 years. At the time of diagnosis 47.3% of patients were < 60 years of age (24.2% < 40 years, 23% 50-59 years, 52.6% > 60 years). At initial diagnosis 12.5% of patients were in stage III and 4.5% in stage IV. The most common type was superficial spreading melanoma (50-660), followed by nodular melanoma (23.5-50%). Apart from the regional and distant lymph node metastases, the most frequent organs involved in stage IV disease were distant skin and soft tissues (12-55%), lungs (19-55.5%), liver (10-60%), and bones (3-10%). The first line therapy in stage IV metastatic melanoma was dacarbazine (DTIC) dimethyl-triazenoimidozole-carboxamide in 61-93% of the patients, while the second line varied between the centers. Disease control (complete response + partial response + stable disease) was achieved in 25.7% of the patients treated with the first line chemotherapy and 23.1% of the patients treated with the second line therapy, but the duration of response was short, in first-line therapy 6.66 +/- 3.36 months (median 6.75 months). More than 90% of patients were treated outside the clinical trials. CONCLUSION: Based on this survey, there is a large unmet need for the new treatment options for metastatic melanoma in Serbia. The development of national guidelines, and greater involvement in international clinical studies could lead to widening of treatment options for this chemotherapy resistant disease.

Increasing frequency of soft tissue sarcomas in Vojvodina - comparison with the literature.

BACKGROUND: Soft tissue sarcomas (STS) represent 1% of all malignant lesions. In this study the authors analyzed the incidence of STS in Vojvodina (the north region of Serbia) in the period from 1985 to 2009. A number of studies conducted worldwide indicate that STS incidence rates are tending to increase. MATERIALS AND METHODS: On the basis of data from the Cancer Registry of Vojvodina, age standardized STS incidence rates were established as well as their linear trend, with data on histological structure, age, gender and STS distribution at specific locations. RESULTS: The total number of registered patients was 1,308. Average age standardized rate was 1.90/100,000 per year. The investigated period showed a slight increase in the incidence rate (average annual percent increase=0.77%). The most frequent histological type was sarcoma not otherwise specified-NOS (27%), followed by leiomyosarcoma (21%), liposarcoma (14%), rhabdomyosarcoma (11%) and malignant fibrous histiocytoma (9%). The male/female ratio was 0.73:1. Every fifth patient was younger than 39. CONCLUSIONS: Comparison among eight international STS epidemiology studies show that the incidence rate range is between 1.4/100,000-5.0/100,000, though our finding is closer to the lower limit. Furthermore, the incidence rate increase was lower than that characteristic for the half of the analyzed studies. A partial explanation for that should be looked for among changes in diagnostic criteria and STS classifications.

[Surgical techniques and outcomes in the treatment of malignant tongue base tumors].

INTRODUCTION: Prognosis of patients with malignant tongue base tumors is poor. Survival is low, in spite of different treatment modalities. Most patients seek treatment too late, when their disease has already progressed to stage III or IV. The aim of this investigation was to compare different treatment modalities in patients with malignant tongue base tumors. MATERIAL AND METHODS: We have analyzed a total of 82 patients (72 men and 6 women) treated at the ENT Clinic, Clinical Center Novi Sad, between 1992 and 2004. The average age of our patients was 59 years. In regard to lifestyle habits, out of 82 patients, 67 were smokers and 57 were alcohol users (16 of the latter were treated alcoholics). The majority (54/82) of patients were both smokers and alcohol users. RESULTS: There were 6% of patients (5/82) with stage I disease, 15% ofJ patients (12/82) with stage 11, 24% of patients (20/82) with stage III and 55% of patient (45/82) with stage IV disease. Planocellular cancer was diagnosed in 79/82 patients, and the remaining (3182) had transitional cell carcinoma. Surgical treatment alone was performed in 17 patients, seven were treated with radiation only, and nine only with chemotherapy. Combined surgical and radiation therapy was performed in 28 patients, and 5 were treated with all three. Ten patients were not treated with any therapy. Tongue base resection only was performed in 12 patients, tongue base resection with epiglottectomy in 20, tongue base resection with supraglottic laryngectomy in 13 and tongue base resection with total laryngectomy in 5 patients. In radiation only cases, 25% of patients survived 20 months, whereas in surger) only cases, 25% of patients survived 27 months. Five-year survival after combined surgical and radiation therapy was 35% CONCLUSION: Development of tongue base carcinoma is strongly associated with alcohol and tobacco consumption. Survival is low, despite various treatment modalities. However, combined therapy is the therapy of choice in cases with tongue base carcinoma.